RENEWAL APPLICATION CHECKLIST - Nevada



Kelly Wuest

Administrator

| |State of Nevada

[pic] | |8778 S Maryland Parkway #115

Las Vegas, Nevada 89123

702.486.7330 Phone

702.486.7340 (Fax) | |

| |

|COMMISSION ON POSTSECONDARY EDUCATION |

|cpe.state.nv.us |

Dear Colleague:

This document contains the forms required to renew your license. Pursuant NRS 394.460 (7) licensed postsecondary institutions must complete and file with the Administrator an application for renewal of its license at least 60 days before the expiration of a license. If you need additional time, you must contact this agency prior to the due date for permission.

The renewal application checklist, which is considered part of the application and must be completed and returned, has instructions for each form. If you have additional questions, contact this agency.

Return the completed application to:

ATTN RENEWALS

COMMISSION ON POSTSECONDARY EDUCATION

8778 S MARYLAND PARKWAY STE 115

LAS VEGAS NV 89123

Sincerely,

Kelly D Wuest

Kelly D. Wuest

RENEWAL APPLICATION CHECKLIST

|NAME OF SCHOOL |NEVADA DIRECTOR |

| | |

| | |

| | |

| |WEB SITE |

|NEVADA MAIN CAMPUS ADDRESS |ADDITIONAL APPROVED NEVADA SITES |

|NAME OF CONTACT/POSTION TITLE |PHONE NUMBER OF CONTACT |

| | |

| | |

| |EMAIL ADDRESS OF CONTACT |

|INITIALS |FORM # |FORM TITLE |

| | |OPTION 1: Complete Forms 20a and 20b |

| |20a | |

| | |RELEASE FOR SUBSTANTIATION OF FINANCIAL DATA |

| |20b |FINANCIAL STATEMENT |

| | |You must complete pages 1 – 4. |

| | |Option 2: Financial statement reviewed or audited by a certified public accountant prepared within the 12 months immediately |

| | |preceding the date on which the license expires. The Release for Substantiation of Financial Data is not required for schools who|

| | |select Option 2. |

| |30e |CURRICULUM VERIFICATION |

| | |Complete for each program which you currently offer. |

| |60 |OWNERSHIP |

| |70 |CATALOG APPROVAL CHECKLIST (ATTACH CURRENT CATALOG) |

| |70a |ENROLLMENT AGREEMENT (ATTACH CURRENT DOCUMENT) |

| |

|In the event of discontinuing operation of this postsecondary educational institution, I hereby agree to immediately submit the transcript records of all |

|students to the Nevada Commission on Postsecondary Education and all records of any students who have not completed their training at the time of closure. |

| |

|Transcript Location: |

| |

|Student Transcript Form: Electronic Paper |

|I declare that the postsecondary educational institution described in this application is in full compliance with the civil rights act as amended (Title VI) and|

|the Americans with disabilities act and that the institution will in no way discriminate on the basis of race |

|I hereby affirm that the private postsecondary educational institution identified in this application operates in accordance with the applicable provisions of |

|NRS and NAC Chapters 394. |

|Under penalty of perjury, I hereby declare the information contained in this renewal application, including all forms and attachments, to be true and correct. |

|TYPE NAME/TITLE OF SCHOOL REPRESENTATIVE |DATE SIGNED |

| | |

|SIGNATURE |

CURRICULUM VERIFICATION (30e)

List each program you offer – it must match your catalog and each program must be on your license.

|NAME OF PROGRAM |□ DEGREE |

| |□ CERTIFICATE |

| |SOLE PROPRIETORSHIP Individual owner/spouse. Financial statement demonstrating ownership and fictitious firm name. Submit registration|

| |with Secretary of State. |

|NAME OF OWNER |AREA CODE & PHONE NUMBER |

| | |

| |EMAIL ADDRESS |

|FULL MAILING ADDRESS |

|NAME OF BUSINESS |PHONE NUMBER |

|BUSINESS ADDRESS |WEB URL |

| |PARTNERSHIP – Submit a copy of partnership agreement and list all partners and/or any entity having any financial investment. Submit |

| |registration with Secretary of State. |

|NAME OF PARTNERSHIP |ADDRESS |PHONE NUMBER |

| | | |

| | |WEB URL |

| | | |

|PARTNER NAME |ADDRESS |PHONE NUMBER |

|PARTNER NAME |ADDRESS |PHONE NUMBER |

|PARTNER NAME |ADDRESS |PHONE NUMBER |

| |CORPORATION – List all entities having a 10% or more interest. Attach articles of incorporation, corporation certificate and include a |

| |listing of all officers. Submit registration with Secretary of State. |

|NAME OF CORPORATION |ADDRESS |PHONE NUMBER |

| | |WEB URL |

|CORPORATE OFFICER/POSITION |ADDRESS |PHONE NUMBER |

|CORPORATE OFFICER/POSITION |ADDRESS |PHONE NUMBER |

|CORPORATE OFFICER/POSITION |ADDRESS |PHONE NUMBER |

| |LIMITED LIABILITY COMPANY including Professional LLC & Foreign LLC – Submit articles of organization and listing of manager /members. |

| |Submit registration with Secretary of State. |

|NAME OF LIMITED LIABILITY COMPANY |ADDRESS |PHONE NUMBER |

| | | |

| | |WEB URL |

| | | |

|MANAGER OR MEMBER |ADDRESS |PHONE NUMBER |

|MANAGER OR MEMBER |ADDRESS |PHONE NUMBER |

| |PUBLIC INSTITUTION – Attach a copy of your state charter. |

| | | | | |

| | | | | |

|SIGNATURE OF OWNER or REPRESENTATIVE | |PRINTED NAME OF OWNER or REPRESENTATIVE | |DATE |

CATALOG APPROVAL CHECKLIST (70)

Enter the page number for each of the following items and return it with two copies of your catalog. Refer to NRS 394.441, 394.449, and NAC 394.381(6). Each item listed below is required to be in the schools catalog.

| |School Name and Effective Date of Catalog |

| | |

|PG # |Item |

| |Name of institution and effective date of catalog: NAC |

| |394.381(6)(a) |

| |Business hours |

| |NAC 394.381(6)(c) |

| |List of all faculty members NAC 394.381(6)(b) & NRS |

| |394.465 |

| |Credit for previous training policy. |

| |NAC 394.381 (6)(j) |

| |Entrance requirements (Must reasonably ensure prospective student is able to complete the training and benefit from it) |

| |NAC 381(6)(d) & NAC 394.607 |

| |List of governing body/owners names NAC |

| |394.381(6)(b) |

| |Description of career services NAC|

| |394.381 (6)(k) |

| |Description of the facility, equipment, available space NAC |

| |394.381(6)(i) |

| |Description of licensure and accreditation status, as applicable NAC 394.381 (6)(l) |

| |Refund policy MUST conform to |

| |NRS 394.449 |

| |Start, stop dates of training programs, registration periods, add, drop, withdrawal dates, school holidays |

| |NAC 394.381(6)(c) |

| |Conduct of students to include description of unsatisfactory conduct and action taken by school for such conduct. |

| |NAC 394.381 (6)(g) |

| |Tuition charges to include complete description of all charges and expenses for each program or course, including registration fees, equipment, |

| |etc. NRS 394.441(1) |

| |Standards of progress |

| |► Description of grading system or method used to evaluate progress: NAC 394.381(e)(1) |

| |► Description of standards of progress including definition of unsatisfactory progress: NAC 394.381(e)(2) |

| |► Description of process followed for students not making satisfactory progress to include readmission: NAC 394.381(e)(3) |

| |Attendance |

| |NAC 394.381(f) |

| |► Maximum number of absences allowed |

| |► Definition of absence, excused, unexcused, leave of absence, tardiness, make-up work, etc. |

| |► Action taken for excessive absences |

| |Program description to include all required units, courses, classes, or subjects, and total hours or credits required for graduation. Briefly |

| |describe each course to show objective, content, and length, in hours or credits. If applicable, list and describe all special classes or |

| |courses. NRS 394.441(1) |

| |

|– CPE USE ONLY – |

|DEFICIENCIES/COMMENTS |

| |

| |

| |

| |

| |

| |

|[pic] |

|SIGNATURE OF REVIEWER DATE |

ENROLLMENT AGREEMENT CHECKLIST (70a)

NON-DEGREE PROGRAMS ONLY

Each item below is required by NAC 394.381(5). Initial or check each item indicating it is on the enrollment agreement.

|School Identification Information |

| |Name |

| |Address |

| |Phone number |

| |Signature/date block |

|Student Identification Information |

| |Student name |

| |Student address |

| |Student phone number |

| |Student signature/date block |

|Statement Requirements |

| |Refund policy in bold print |

| |Disclaimer in bold print that placement in a job is not guaranteed nor promised to graduates |

| |Effective date of catalog under which the student is enrolled |

| |Statement in bold print that the person signing the enrollment agreement understands it and has received a copy of the |

| |catalog or brochure and understands it is part of the enrollment agreement |

|Program Information |

| |Full name of training program |

| |Actual number of credits AND hours to complete the training program |

| |Start date of training program |

| |Total cost of the training program |

|Funding Information |

| |Schedule of payments, if applicable |

| |Policy of credit for previous training and any reduction in cost and length of training program |

| |Provisions required by any outside source for student bound by a document of indebtedness |

| |

|– CPE USE ONLY – |

|DEFICIENCIES/COMMENTS |

| |

| |

| |

| |

|[pic] |

|SIGNATURE OF REVIEWER DATE |

|FINANCIAL STATEMENT 20b |

|NAME OF SCHOOL |ADDRESS |PHONE NUMBER |

| | | |

|NAME OF SCHOOL OFFICIAL |POSITION |PHONE NUMBER |

| | | |

|LIST ALL INVESTORS AND ENTITIES PROVIDING LOANS MORE THAN $500: |

|NAME OF LENDER |ADDRESS |AMOUNT |

| | | |

| | | |

| | | |

|NAME OF INVESTOR |ADDRESS |RELATIONSHIP |AMOUNT |

| | | | |

|NAME OF INVESTOR |ADDRESS |RELATIONSHIP |AMOUNT |

| | | | |

|NAME OF INVESTOR |ADDRESS |RELATIONSHIP |AMOUNT |

| | | | |

|LIST ALL INDIVIDUALS WHO HAVE A ROLE IN MANAGING THE SCHOOL: |

|NAME |ADDRESS |PHONE # |POSITION/TITLE |

| | | | |

|NAME |ADDRESS |PHONE # |POSITION/TITLE |

| | | | |

|NAME |ADDRESS |PHONE # |POSITION/TITLE |

| | | | |

| | | | |

| | | | |

|NAME |ADDRESS |PHONE # |POSITION/TITLE |

| | | | |

|LIST EACH FINANCIAL INSTITUTE WHICH THE SCHOOL USES: |

|NAME OF FINANCIAL INSTITUTION |ADDRESS |ACCOUNT # |

| | | |

|NAME OF FINANCIAL INSTITUTION |ADDRESS |ACCOUNT # |

| | | |

|NAME OF FINANCIAL INSTITUTION |ADDRESS |ACCOUNT # |

| | | |

|YES |NO |PLEASE CHECK THE APPROPRIATE ANSWER: |

| | |Has your interest in the school been assigned, pledged or hypothecated to any person, firm corporation, or has any agreement been entered |

| | |into whereby your interest is to be assigned, pledged or sold, either in parts or whole? If yes, attach a detailed explanation. |

| | |Have you or any principal ever filed for bankruptcy? If yes, attached a detailed explanation and include all court documents pertaining |

| | |the filing. |

| | |Would you voluntarily submit a copy of your most recent federal income tax return? |

| |

|FULL NAME UNDER WHICH THE OWNER’S FEDERAL INCOME TAX RETURN WAS FILED |DATE FILED | |

| |PAGE 1 OF 4 |

|STATEMENT OF ASSETS |

|THE FOLLOWING IS A COMPLETE LIST OF ASSETS CURRENT AS OF |DATE |

|CASH ON HAND |AMOUNT |

| | |

| |$ |

|RECEIVABLE DESCRIPTION |DUE DATE |COLLECTIBLE? |AMOUNT |

| | | | |

| | |□ Yes □ No |$ |

| | | | |

| | | | |

|RECEIVABLE DESCRIPTION |DUE DATE |COLLECTIBLE? |AMOUNT |

| | | | |

| | |□ Yes □ No |$ |

| | | | |

|RECEIVABLE DESCRIPTION |DUE DATE |COLLECTIBLE? |AMOUNT |

| | | | |

| | |□ Yes □ No |$ |

| | | | |

| | | | |

|STOCKS/BONDS/SIMLAR ASSETS |MARKET VALUE |

| | |

| |$ |

|STOCKS/BONDS/SIMLAR ASSETS |MARKET VALUE |

| | |

| |$ |

|REAL ESTATE/BUILDINGS |MARKET VALUE |

| | |

| |$ |

|PERSONAL PROPERTY/EQUIPMENT/ETC. |VALUE |

| |$ |

|PERSONAL PROPERTY/EQUIPMENT/ETC. |VALUE |

| | |

| |$ |

|PERSONAL PROPERTY/EQUIPMENT/ETC. |VALUE |

| | |

| |$ |

|TOTAL ASSETS |$ |

| |

|List from assets above which can be converted for use by the school: |

| |

| |

| |

| |

| |PAGE 2 OF 4 |

|STATEMENT OF LIABILITIES |

|THE FOLLOWING IS A COMPLETE LIST OF LIABILITIES CURRENT AS OF |DATE |

|MORTAGES/RENT PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

|MORTAGES/RENT PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

|STAFFING COSTS |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

|NOTE PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

| | | | | |

|NOTE PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

|NOTE PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

| | | | | |

|CONTINGENT LIABILITY PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

| | | | | |

|CONTINGENT LIABILITY PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

|OTHER LIABILITY PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

|OTHER LIABILITY PAYABLE TO |HOW SECURED |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | | |

| | |$ | |$ |

|ACCOUNTS PAYABLE TO |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | |

| |$ | |$ |

|ACCOUNTS PAYABLE TO |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | |

| |$ | |$ |

|ACCOUNTS PAYABLE TO |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | |

| |$ | |$ |

|ACCOUNTS PAYABLE TO |PAYMENT AMT |PAYMENT FREQUENCY |TOTAL AMT |

| | | | |

| |$ | |$ |

| | | | |

|CURRENT FEDERAL TAX PROVISION |$ |

|FEDERAL TAX LIABILITY |$ |

|FEDERAL TAX LIABILITY |$ |

|CURRENT OTHER TAX LIABILITY |$ |

|TOTAL LIABLITIES |$ |

| |PAGE 3 OF 4 |

|Commission on Postsecondary Education |

| |

|Certification Of Financial Statement |

|The undersigned, being duly sworn, depose and says that the statements contained in the financial statement are true and correct to the best of his knowledge |

|and belief, and that this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient |

|cause for the refusal to issues or for the revocation of a private postsecondary educational institution license. Furthermore, the undersigned is voluntarily|

|submitting this financial statement and financial information under oath with full knowledge that the Postsecondary Education Authorization Act of Nevada |

|provides for civil penalties in violation of regulations. |

|SCHOOL NAME |LOCATIONS |

|TYPE NAME OF APPLICANT |SIGNATURE OF APPLICANT/DATE SIGNED |

| |

|Signature witnessed by NOTARY PUBLIC on this _____________ day of __________________, in the year of ____________. |

| |

|Notary Public in and for the County of ______________________________, State of ________________________. |

| |

| |

|NOTARY SIGNATURE AND SEAL: |

| |

| |

| |

| |

| |

| |

| |

| |PAGE 4 OF 4 |

RELEASE FOR SUBSTANTIATION OF FINANCIAL DATA (20a)

|FULL NAME OF SCHOOL OWNER |NAME OF SCHOOL |

| | |

|1. |I hereby authorize and request, for a period of six months from the date above, all persons to whom this request is presented having information |

| |relating to my financial condition, to furnish such information to an employed agent of the Nevada Commission on Postsecondary Education (CPE). |

|2. |If the person to whom this request is presented is a brokerage firm, bank, savings and loan, other financial institution, or officer of same, I hereby|

| |authorize and request that an employed agent of CPE be permitted to review and copy such information as is used in determining assets and liabilities |

| |of an individual or corporation and the financial solvency of such an individual or corporation. |

|3. |I do hereby make, constitute and appoint any employed agent of CPE my true and lawful attorney in fact for me in name, place and stead, and on my |

| |behalf and for my use and benefit: |

| |a. |To request, review and copy or otherwise act for financial investigative purposes with respect to documents and information in the possession of|

| | |the person to whom this request is presented as I might or could do if personally present. |

| |b. |To name the person or entity to whom this request is presented and to insert that person's name in the appropriate location on this request. |

| |c. |To place the name of the CPE agent presenting this request in the appropriate location on this request. |

|4. |I have filed with CPE an "application" as that term is defined in the Nevada Revised Statutes (NRS) Chapter 394 and Nevada Administrative Code (NAC) |

| |Chapter 394 for licensure of a private postsecondary educational institution. I understand that I am seeking the granting of a privilege and |

| |acknowledge that the burden of proving my qualifications, including my financial soundness and stability, for a favorable determination, is at all |

| |times on me. |

|5. |I agree to indemnify and hold harmless the person to whom this request is presented and his agent and employees, from and against all claims, damages,|

| |losses, and expenses, including reasonable attorney fees arising out of or by reason of complying with this request. |

|6. |I understand that I am afforded all due process and appeal rights as are described in NRS and NAC Chapters 394. |

|7. |A reproduction of this request by electronic copier or similar process shall be as valid as the original. |

|NAME OF BANK |NAME AND PHONE NUMBER OF BANK CONTACT |

|ADDRESS OF BANK |ACCOUNT NUMBER |

IN WITNESS WHEREOF, I have executed this request in the COUNTY of _____________________, in the STATE of _____________________,

on this ________ day of __________________, in the year of __________.

__________________________________________________________

SIGNATURE OF APPLICANT/OWNER

Signature witnessed by NOTARY PUBLIC on this __________ day of _____________________, in the year of ____________.

NOTARY SIGNATURE AND SEAL: _________________________________________________________________________

– CPE USE ONLY –

_________________________________________________

SIGNATURE OF CPE REPRESENTATIVE/DATE

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download